Health care—what to do next, and how to do it—is likely to be a flash point in the first debates of the 2020 Democratic presidential nomination process. All the Democratic candidates support universal coverage, but they differ on how to provide it.
Background: The Competing Proposals
Medicare for All
Sen. Bernie Sanders (D-VT) laid down a marker with a Senate bill that was cosponsored by his presidential campaign rivals Sens. Cory Booker (D-NJ), Kirsten Gillibrand (D-NY), Kamala Harris (D-CA) and Elizabeth Warren (D-MA), but conspicuously not by Sens. Amy Klobuchar (D-MN) or Michael Bennet (D-CA). Rep. Tulsi Gabbard (D-HI) is the cosponsor of a companion bill in the House.
Medicare-X Choice Act
Medicare-X Choice Act, introduced by Sens. Michael Bennet and Tim Kaine (D-VA), and cosponsored by Sen. Amy Klobuchar (and Sens. Harris and Booker, and endorsed by Mayor Pete Buttigieg), would build on the Affordable Care Act by creating a public option via Medicare. This public option would have to cover the minimum set of benefits prescribed by the ACA. ACA tax credits would be expanded for low-income purchasers.
Medicare at 50 Act
An incremental bill was introduced by Sen. Debbie Stabenow (D-MI) and Rep. Brian Higgins (D-NY). Stabenow’s Senate version is cosponsored by Sens. Gillibrand, Klobuchar, Harris and Booker. This bill would simply allow Americans between 50 and 64 to buy into Medicare.
What to Watch For in the Debates
The Debate Moderators’ Approach
One way for the moderators to approach the macro subject of health care reform is to emphasize the split between the Medicare for All supporters and the advocates of a less disruptive approach. To generate heat, moderators should press proponents, especially Sanders, on the differences between his theoretical version of Medicare (much more generous benefits) and the program as it exists today. Sanders’ proposal would eliminate private insurance, a less-noticed fact that may make supporters uncomfortable. Finally, Sanders’ program might eventually produce savings from greater efficiency and widespread preventive care, but it would initially be monumentally expensive.
Sanders has proposed the most elaborate and expensive program, but he’s not the only Democrat who might be tested on cost. Dems have taken two approaches to the cost of comprehensive reform: insist that the savings the program generates will offset the costs, or assert that they can cover the costs by repealing Trump’s tax breaks for the wealthy (or enacting new taxes on the wealthiest Americans). Both of these approaches create openings for aggressive moderators and for cross-candidate challenges (i.e., real debate!).
Night One and Night Two Lineups Create Opportunities—and Hazards
The moderators ask the questions, but they may be governed in their choices by each night’s specific roster.
Unfortunately for viewers spoiling for a health care fight, the contestants most likely to mix it up, John Delaney and Bernie Sanders, will not appear together (Delaney: Night One; Sanders: Night Two). However, it is possible to visualize Delaney and Amy Klobuchar agreeing on an incremental approach to health care reform.
Gov. Jay Inslee may have an opening here; as the only governor on Night One, he can relate experience administering health plans (including Medicaid) statewide. Inslee recently signed a bill to create Cascade Care, a statewide public option program, which goes into effect by 2021.
On Night Two, Michael Bennet can assume the role of political realist by touting his bill as an alternative to Berniecare. Bennet has been very direct in his critique of Medicare for All, noting the Urban Institute’s estimated price tag of $32 trillion. Bennet is also ready to point out that Sanders’ home state of Vermont rejected a single-payer ballot initiative when confronted with the requirement for large tax increases. Night Two has more Medicare for All supporters than Night One—Sanders, Gillibrand, Harris and Yang—which means that Bennet has a great chance to stand out.
Sanders, who is losing ground to Elizabeth Warren in recent polls, can’t just play defense on Medicare for All. To impress progressive voters, he needs to use health care to chip away at Joe Biden’s lead. That means challenging Biden to defend his “Medicaid for all” proposal. Biden probably won’t engage Bernie on substance; the smart play for him is to cite his role in helping President Barack Obama get the Affordable Care Act through Congress.
Biden faces what I believe is a more pressing threat from the female candidates he’ll share the stage with on Night Two. Harris and/or Gillibrand can underscore the importance of a candidate’s sex and take a jab at front-runner Biden by vowing to restore Medicaid funding for abortion. (But not so much Marianne Williamson, who may get stuck defending the anti-vaxxer position she seemed to adopt recently). This would put Biden between the Scylla and Charybdis of re-explaining his shift on this issue or ignoring it completely. Like Sanders, Harris and Gillibrand need to pry voters away from Biden.
Finally, Biden’s view of the health care system was sharpened by the death of his son Beau in 2015. He may well raise this for personal, not tactical reasons.
Keep the Real Audience in Mind
While it should be possible to score debating points off Sanders, viewers should keep in mind that the judgement that matters is not that of the moderators or the press generally, it’s that of Democratic primary voters. Given that, Sanders’ competitors may be wary of calling him out. I would expect Bennet and Klobuchar to take the two most prominent examples, to position themselves not as moderates, but as realists who share the same goal of universal coverage, but have more practical plans to get us there.
Hot Topics Are Not Always Debate Topics
Positions that are controversial outside the debate hall are not necessarily controversial inside. The moderators would be well-advised to avoid issues, no matter how timely, where all of the Democratic candidates are substantially in agreement. Prescription drug prices, opioid use, balance billing, stem cell research, these are issues that each candidate will talk about on the stump, and might be very suitable for general election debates, but they wouldn’t create much drama or help voters sort out Democratic candidates in a debate.
Predicting what’s going to happen in debates isn’t an exact science, especially with 20 candidates and five moderators. With that in mind, we’ve tried to predict how health care reform will be treated in this week’s debates. Please feel free to email Drew Littman with comments or questions.
This document is intended to provide you with general information regarding the issue of health care in the Democratic presidential debates. The contents of this document are not intended to provide specific legal advice. If you have any questions about the contents of this document or if you need legal advice as to an issue, please contact the attorneys listed or your regular Brownstein Hyatt Farber Schreck, LLP attorney. This communication may be considered advertising in some jurisdictions.